Georgia Licensed Clinical Review Nurse

Job Summary

Supporting the Ambetter marketplace members in Georgia, the full-time remote Georgia Licensed Clinical Review Nurse will perform concurrent reviews to evaluate members' overall health, assess the necessity of care, and contribute to discharge planning according to established guidelines.

Key responsibilities

• Conduct concurrent reviews to determine appropriate care and setting for members
• Collaborate with Medical Affairs and healthcare providers to validate care delivery and approve medical determinations
• Document and maintain findings in health management systems in compliance with utilization management policies

Required qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience, including 2+ years of acute care experience
• Current Georgia RN state licensure or Compact RN licensure
• Knowledge of Medicare and Medicaid regulations preferred
• Familiarity with utilization management processes preferred